Medical apparatus and method for attaching a suture to a bone

ABSTRACT

A method of forming a channel in a bone, the method comprising: providing a first bore in the bone; and forming, a second bore in the bone at a predefined angle from said first bore, using said first bore as a reference point for defining the location of the second bore in the bone, wherein the first and second bores intersect in the bone.

RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.12/919,516 filed on Aug. 26, 2010, which is a National Phase of PCTPatent Application No. PCT/IL2008/001316 having International filingdate of Oct. 5, 2008, which claims the benefit of priority of U.S.Provisional Patent Application Nos. 61/129,394 filed on Jun. 23, 2008and 61/064,333 filed on Feb. 28, 2008. The contents of the aboveapplications are all incorporated by reference as if fully set forthherein in their entirety.

FIELD AND BACKGROUND OF THE INVENTION

The present invention relates to medical apparatus, particularly to amedical implement and a kit including such an implement, and also to amethod, for attaching a suture to a bone. The invention is especiallyuseful in an arthroscopic surgical procedure for attaching a tendon of arotator cuff muscle to the humerus bone for repairing a damaged shoulderjoint, and is therefore described below with respect to such aprocedure.

While the shoulder joint has a great range of motion, it is not verystable. Four rotator cuff muscles (supraspinatus, infraspinatus,subscapularis and teres minor) surround the shoulder joint and providethe power to lift and rotate the arm while keeping the head of the upperarm bone (humerus) in approximation to the socket in the shoulder blade(glenoid) for stability. Each of these muscles is attached by a tendonto the humerus bone. The supraspinatus muscle is attached by thesupraspinatus tendon to the superior aspect of the greater tubercle. Theinfraspinatus muscle is attached by the infraspinatus tendon to theposterolateral aspect of the greater tubercle. The teres minor muscle isattached by the teres minor tendon to the lower aspect of the greatertubercle. The subscapularis muscle is attached by the subscapularistendon to the lesser tubercle. As one ages, these muscles and tendonsbecome thinner and prone to rupture. A rotator cuff tear may developgradually or may result suddenly from a single traumatic event. In ayounger patient, rupture is usually associated with significant trauma.Rotator cuff tears are tears of one or more of the four tendons of therotator cuff muscles listed above. Tears of the surpraspinatus tendonare the most common, most often involving detachment of the tendon fromthe bone. The tear of the supraspinatus tendon usually occurs at itspoint of insertion onto the humeral head at the greater tubercle. Sincethis tear is the most common, the following description will refer tothe supraspinatus tear. However, it is submitted that the inventiondescribed below is applicable to any of the rotator cuff tears and infact to any tear of a tendon from a bone.

When surgical intervention is indicated to repair a rotator cuff tear,the procedure can be performed as an open surgical procedure, or as aminimally invasive (arthroscopic) surgical procedure. Both proceduresaim to re-attach the tendon to the bone over an area extending from theanatomical neck to the lateral surface of the tubercle. The relativelylarge area of attachment is desirable for strengthening purposes and forassisting recovery and healing. This procedure of osseointegration ofthe tendon to the bone causes bony tissue to be formed around the tendonand anchors it in place.

In open surgery, after the joint has been exposed, the tubercle isaccessed laterally, and a row of holes are drilled aiming to exit in thearea of the anatomical neck. Sutures are led through these holes; thetendon is stretched to lie over the planned area of attachment; and thesuture coming from the exit point is passed through the tendon. When thesutures leading from the inlet and exit points are knotted, one strandoverlies the tendon, thus achieving attachment over the surface of thetubercle from the lateral inlets to the anatomical neck.

In contrast, the arthroscopic procedures use bone anchors. Two rows ofanchors are implanted, one in the neck area and one on the lateralsurface of the tubercle. Sutures leading from the anchors are passedthrough the tendon and are knotted over it.

Both procedures have shortcomings. With the open method, the bonetunnels for the sutures can be drilled only in one direction, from thelateral upwardly to the anatomical neck. Access for drilling from theanatomical neck at an angle to reach the side of the tubercle isobstructed by the patient's neck and head. It is difficult to achieveexactly the desired exit points for the drill. Exiting on the sphericalhumeral head must be avoided. Drilling at a more acute angle for safetymay result in being too close to the surface of the tubercle.

A minimally invasive (arthroscopic) method is desirable when notcontra-indicated from medical considerations. However, the conventionalarthroscopic procedure uses anchors resulting in points or lines ofattachment, rather than in attachments over a significant surface.

OBJECTS AND BRIEF SUMMARY OF THE PRESENT INVENTION

Objects of the present invention are to provide a medical implement, akit including such an implement, and a method, for attaching a suture toa bone having advantages in one or more of the above respects andparticularly useful in an arthroscopic surgical procedure.

There is thus provided in accordance with an exemplary embodiment of theinvention a method of forming a channel in a bone, the methodcomprising:

providing a first bore in the bone; an

forming, a second bore in the bone at a predefined angle from said firstbore, using said first bore as a reference point for defining thelocation of the second bore in the bone, wherein the first and secondbores intersect in the bone.

In an exemplary embodiment defining the location further comprisesdefining the depth of the second bore such that the second boreintersects with the first bore but will not exit the bone except at asingle point.

Optionally, using said first bore as a reference point comprisesinserting a hook in said first bore. Optionally, said hook and a drillfor forming said second bore are linked such that the second bore is ata predetermined angle from the first bore.

Optionally, forming said second bore comprises forming such that thesecond bore extends past the intersection of the first and second borein the bone. Optionally, forming said second bore comprises forming suchthat the second bore does not cross the bone.

In an exemplary embodiment said bone is a humerus bone.

There is further provided in accordance with an exemplary embodiment ofthe invention, a method of forming a bore in a bone, the methodcomprising:

providing a first bore in the bone;

providing an implement comprising a hook having an end portion forinsertion in the first bore and a passageway for receiving tools, thepassageway being at a non-zero angle to the portion;

inserting the hook in the first bore;

clamping the implement to the bone using the hook as an arm of theclamp;

forming a second bore using a drill inserted through said passageway inthe implement, such that the first and second bore intersect in thebone.

In an exemplary embodiment, said implement further comprises a lockingmechanism for clamping the implement to the bone. Optionally, forming asecond bore comprises forming a second bore extending past theintersection of the first and second bore in the bone. Optionally,forming a second bore comprises forming a second bore which does notexit the bone at more than one point.

In an exemplary embodiment, said bone is a humerus bone.

There is further provided in accordance with an exemplary embodiment ofthe invention, a method of attaching a suture to a bone, the methodcomprising:

providing a first and second bore in a bone, the first and second boresintersecting in the bone;

providing a suture having a first and second end;

threading the first end of a suture through the second bore, whileleaving the second end outside the bone;

capturing the first end of the suture from the first bore at theintersection of the bores in the bone; and

threading the first end of the suture through the first bore.

Optionally, said suture is also threaded through a tendon. Optionally,the method further comprises knotting the first and second ends of thesuture.

In an exemplary embodiment, said bone is a humerus bone.

There is further provided in accordance with an exemplary embodiment ofthe invention, a medical implement for forming a bore in a bone,comprising:

a hook for inserting in a first bore in a bone;

a passageway for receiving tools;

wherein said passageway is adapted for receiving a drill for forming asecond bore in a bone when said hook is inserted in the first bore, andwherein the second bore is oriented with respect to the hook such thatsaid second bore intersects with the first bore in the bone.

Preferably, the second bore is oriented with respect to the hook suchthat the first bore and second bore define a predefined angle.

Optionally, said drill comprises a stop adapted to define the depth ofthe second bore to be formed. Optionally, said implement furthercomprises a locking mechanism for clamping the implement to the bone.

In an exemplary embodiment, said locking mechanism consists of a firstand a second element which clamp the bone between them and wherein saidfirst element is the hook inserted into the first bore. Preferably, saidpredefined angle is 70°. Optionally, said predefined angle is between65° and 75°.

There is further provided in accordance with an exemplary embodiment ofthe invention, a medical implement for forming a bore in a bone,comprising:

a hook for inserting in a first bore in a bone; and

a passageway for placement at an entrance to a second bore in the bone,

wherein said hook comprises a loop extending thereform, said loop beingadapted to grasp an end of a suture inserted through the passageway andthrough the second bore.

Optionally, said hook is further adapted to extract the suture throughthe first bore. Optionally, said implement further comprises a lockingmechanism for clamping the passageway against the bone when the hook isinserted into the first hole.

There is further provided in accordance with an exemplary embodiment ofthe invention, a medical implement for forming a bore in a bone, theimplement comprising:

a hook for inserting in a first bore in a bone;

a passageway for placement at an entrance to a second bore in the bone;and

a locking mechanism for clamping the passageway against the bone,

wherein said locking mechanism consists of a first and a second elementwhich clamp the bone between them and wherein said first element is thehook inserted into the first bore.

There is further provided in accordance with an exemplary embodiment ofthe invention a medical kit of instruments for forming a bore in a bone,comprising:

a first drill for drilling a first bore in a bone;

a second drill for drilling a second bore in the bone;

a suture for threading through said first and second bores in the bone;and

a medical implement according to any of claims 40-51.

Optionally, said kit further comprises: a drill guide for receiving saidfirst drill and forming said first bore.

In an exemplary embodiment said second drill is thinner then said firstdrill.

Optionally, said first and second drills comprise a stop such that saidfirst bore formed with said drill does not pass through the bone.

Optionally, said kit further comprises a suture loader for threadingsaid suture through said second bore.

According to one aspect of the invention, there is provided a medicalimplement for attaching suture to a bone, particularly useful inarthroscopic surgical procedures, comprising a handle having a proximalend for manual grasping and a distal end for engagement with a bone towhich a suture is to be attached, the bone being pre-formed with a firstbore for receiving one end of the suture; a hook carried at the distalend of the handle, spaced from an outer surface at the distal end of thehandle, and configured for reception in the first bore of the bone; thehook or distal end of the handle being in the form of a movable membermovable to an extended position with respect to the other to facilitatereception of the hook into the first bore, and to a retracted positionwith respect to the distal end of the handle for clamping the handle tothe bone at a predetermined angle with respect to the first bore; and amanually manipulatable member carried by the proximal end of the handleand coupled to the movable member for moving the movable member to theextended and retracted positions; the handle being formed with apassageway extending longitudinally therethrough from its proximal endto its distal end, the passageway being configured for receiving adrill, after the handle has been clamped to the bone, for drilling asecond bore through the bone at the predetermined angle with respect tothe first bore and, after the drill has been removed from thepassageway, for passing through the passageway the one end of the sutureto traverse, and to extend past, the first bore such that the one end ofthe suture is accessible through the first bore for being pulled outtherefrom, while the opposite end of the suture is accessible throughthe second bore for pulling out therefrom in order to attach the sutureto the bone.

Two embodiments of the invention are described below for purposes ofexample. In one described embodiment, the movable member is the hook,and is movable to its extended and retracted positions with respect tothe distal end of the handle. In a second described embodiment, themovable member is the distal end of the handle, which is movable to itsextended and retracted positions with respect to the hook.

In both described preferred embodiments, the hook includes a loopmovable to an extended position with respect to the hook forfacilitating entry of the first end of the suture through the loop intothe first bore of the bone, and to a retracted position towards the hookfor clamping the first end of the suture to enable pulling-out the firstend of the suture through the first bore of the bone. In addition, thehandle includes a second manually manipulatable member carried by theproximal end of the handle and coupled to the handle for moving the loopto its extended and retracted positions.

In another described embodiment, the first end of the suture is accessedthrough the first bore in the bone, and pulled out, by a suture hook.

According to another aspect of the present invention, there is provideda medical kit useful for attaching a suture to a bone, the kit includinga medical implement as described above, and a drill receivable withinthe passageway of the handle for drilling the second bore in the bone;the drill including a stop engageable with the proximal end of thehandle to fix the length of the second bore to extend for a slightdistance past the first bore, to thereby permit the first end of thesuture to traverse and extend past the first bore in order to facilitateits access and extraction via the first bore.

According to a still further aspect of the present invention, there isprovided a method for attaching a suture to a bone particularly in anarthroscopic procedure, comprising: forming a first bore in the bone;forming a second bore in the bone intersecting the first bore andextending at a predetermined angle thereto; introducing into the secondbore a first end of a suture to extend through the second bore past theintersection of the second bore with the first bore, with the oppositeend of the suture extending outwardly of the second bore; accessing thefirst end of the suture via the first bore; and extracting the first endof the suture via the first bore, to enable attaching the suture to thebone via the end of the suture.

As will be described more particularly below, the invention enables thesurgeon to perform bone tunnels in the bone in exactly the requiredlocations to receive sutures, and thereby to achieve reattachment of thetorn tendon without the use of bone anchors, in a manner similar to thatof the open surgical procedure. The invention is therefore particularlyuseful in an arthroscopic surgical procedure, but may also be used in anopen surgical procedure.

Further features and advantages of the invention will be apparent fromthe description below.

BRIEF DESCRIPTION OF THE DRAWINGS

The invention is herein described, by way of example only, withreference to the accompanying drawings, wherein:

FIGS. 1A, 1B and 1C illustrate the construction of the shoulder joint tobe repaired according to an embodiment of the present invention,including the construction of the upper part of the humerus bone (FIG.1A), a schematic section through the shoulder joint (FIG. 1B), and adamaged shoulder joint (FIG. 1C) to be repaired;

FIG. 2 is a perspective view of one preferred embodiment of a medicalbone-tunneling implement constructed according to the present inventionfor use in repairing a damaged shoulder joint;

FIG. 3 is an enlarged detailed view of the distal end of the medicalimplement of FIG. 2, and particularly the loop projecting from the hookat the distal end;

FIG. 4 is a top view of the implement of FIG. 2;

FIG. 5 is a sectional view along line V-V of FIG. 4;

FIGS. 6A and 6B are enlarged fragmentary views of the encircled portionsof FIG. 5;

FIG. 7 is a side view of the medical implement of FIG. 2;

FIG. 8 is a sectional view along line VIII-VIII of FIG. 7;

FIG. 9 is an enlarged detail view of the encircled portion of FIG. 8;

FIGS. 10A-10D are enlarged views of the hook at the distal end of themedical implement of FIG. 2;

FIG. 11 illustrates the contents of a medical kit including theimplement of FIG. 2, together with other implements, particularly usefulfor performing an arthroscopic surgical procedure according a preferredembodiment of the invention described herein;

FIG. 12 more particularly illustrates the construction of the sutureloading needle in the medical kit of FIG. 11;

FIGS. 13A and 13B are enlarged fragmentary views of the encircledportions of FIG. 12;

FIG. 14 illustrates a suture hook which may be included in the medicalkit of FIG. 11 for use in performing the arthroscopic surgical procedureaccording to another embodiment of the invention;

FIG. 15 is an enlarged fragmentary view of the encircled portion of FIG.14;

FIG. 16 is a perspective view of a second preferred embodiment of amedical bone-tunneling implement constructed according to the presentinvention for use in repairing a damaged shoulder joint;

FIGS. 17 and 18 are top and side views, respectively, of the medicalimplement of FIG. 16;

FIG. 19 is a longitudinal sectional view along section line A-A of FIG.17;

FIG. 20 is an enlarged fragmentary view of encircled portion B of FIG.19;

FIG. 21 is an enlarged fragmentary view of the encircled portion C ofFIG. 19;

FIG. 22 is a flow diagram of a method of attaching a suture to a bone inaccordance with an exemplary embodiment of the invention;

FIGS. 23A-J are schematic illustrations of phases of the method of FIG.22; and

FIG. 24 is a schematic illustration of an implement used for repairing adamaged shoulder joint in accordance with another exemplary embodimentof the invention.

It is to be understood that the foregoing drawings, and the descriptionbelow, are provided primarily for purposes of facilitating understandingthe conceptual aspects of the invention and possible embodimentsthereof, including what is presently considered to be a preferredembodiment. In the interest of clarity and brevity, no attempt is madeto provide more details than necessary to enable one skilled in the art,using routine skill and design, to understand and practice the describedinvention. It is to be further understood that the embodiments describedare for purposes of example only, and that the invention is capable ofbeing embodied in other forms and applications than described herein.

DESCRIPTION OF PREFERRED EMBODIMENTS OF THE INVENTION

An aspect of some embodiments of the invention relates to attaching atendon to a bone by threading a suture through a channel in the bone andthrough the tendon. In an exemplary embodiment of the invention, thechannel comprises of a first and a second bore intersecting in the bone.In an exemplary embodiment of the invention, the intersection of thebores define a predetermined angle between them, suitable for attachinga tendon to the bone by threading a suture through the bores and thetendon. Preferably, the first and second bores are formed in anarthroscopic procedure.

In an exemplary embodiment, the first bore is formed first and is thenused to assist forming the second bore. Optionally, the first bore isused as a reference point for determining the location and/or alignmentof the second bore in the bone. Alternatively or additionally, thereference point is used for determining the depth of the second boresuch that the first and second bores intersect in the bone. Optionally,at least one of the first and second bore extends past the intersectionof the bores in the bone such that a hook or loop may be inserted in oneof the bores, crossing the intersection of the bores in the bone, toconveniently capture a suture inserted via the other bore.

In an exemplary embodiment of the invention, a hook inserted into thefirst bore is used for clamping an implement, with which the second boreis formed, to the bone, thereby stabilizing the implement when drillingthe second bore. Optionally, the hook extending from the implement isinserted into the first bore and is used as an arm for the clamp. Theimplement is then locked in a position clamped to the bone, with thefirst bore as both a reference and a holding point for the implement.The second bore is then formed by a tool preferably guided by apassageway in the implement. Optionally, the hook has a tip in the formof a rod, inserted in the first bore.

An aspect of some embodiments of the invention relates to threading asuture though the second bore and extracting the suture through thefirst bore. In an exemplary embodiment of the invention an end of asuture is threaded through the second bore and grasped at theintersection of the bores in the bone by a loop extending from the hookinserted through the first bore. The loop with the suture is thenextracted through the first bore. Optionally, said loop is replaced withany other suitable mechanism known in the art for grasping a suture, forexample, a hook.

In an exemplary embodiment of the invention there is provided animplement comprising a hook for insertion into a first bore. In anexemplary embodiment, the hook comprises a mechanism configured to graspan end of a suture threaded through the second bore at the intersectionof the bores in the bone. Optionally, the mechanism is furtherconfigured to thread the end of the suture through the first bore whenextracting the hook from the bore. Optionally, said mechanism comprisesa loop. Optionally, the loop is movable between an extracted position inwhich it is removed from the bore and an extended position in which itis extended into the intersection of the bores to grasp the end of thesuture.

In an exemplary embodiment of the invention, the implement comprising ahook further comprises a passageway for receiving tools for forming ofor inserting into a second bore. Optionally, the hook and the passagewayare located such that when the hook is inserted into the first bore, adrill inserted through the passageway is configured to drill a secondbore at a predefined angle from the first bore. Optionally, thepredefined angle is 70°. Alternatively, the predefined angle is between65° and 75°. Alternatively, the predefined angle is between 30° and120°.

Optionally, the drill is further configured to aid in determining thedepth of the second bore to be drilled, by reference to the position ofthe hook which is inserted in the first bore. In an exemplary embodimentof the invention, the drill is configured such that the depth of thesecond bore to be drilled is suitable for different bones of a pluralityof subjects and does not require adjustment for specific bones.

Optionally, the implement further comprises a locking mechanism forclamping the implement to the bone when the hook is inserted into thefirst bore.

In an exemplary embodiment, the first and second bores are formed with asame implement comprising of two channels for receiving tools such as adrill and a suture. In this embodiment the two bores are formed at thesame side of the bone and the angle formed between the bores ispreferably less than 45°.

In the following description reference will be made to attaching asupraspinatus tendon to a humerus bone. However, it is understood thatthe invention may be adapted to attach any tendon or other soft tissueto any bone of a body.

The Shoulder Joint and its Repair (FIGS. 1A-1C)

FIG. 1A schematically illustrates the structure of the upper part of ahumerus bone 2. It includes a spherical head 3 for reception in theglenoid socket 4, and an anatomical neck 5 joined to a greater tubercle6 and a lesser tubercle 7. The juncture of the latter with the humerusbone 2 is a surgical neck 8.

FIG. 1B is a schematic coronal section through the shoulder joint,showing: a supraspinatus tendon 10 of a supraspinatus muscle 11, thegreater tubercle 6, and a shoulder blade (scapula) 12.

FIG. 1C schematically shows the separation of the tendon 10 from thegreater tubercle 6 in a damaged shoulder joint which is to be repairedby the reattachment of the tendon.

As will be described below, this is accomplished, according to someembodiments of the present invention, by forming two bores B₁ and B₂(FIG. 1C). The tendon is captured and drawn toward the left in thefigure, so that it covers bore B₂, as described below and a suture orsutures are passed through the two bores and through the tendon 10; andknotting the two ends of the suture or sutures, to thereby firmly attachthe tendon to the bone. As will also be described below, the inventionenables the two bores B₁, B₂ to be conveniently made in their requiredlocations and at a predetermined angle to each other to achieve thereattachment of the torn tendon by sutures, rather than by bone anchors,in a manner similar to the open surgical procedures, thereby enabling anarthroscopic surgical procedure to be used for repairing a damagedshoulder joint.

The Medical Implement of FIGS. 2-10D

The medical implement illustrated in FIGS. 2-10D is a bone-tunnelingimplement according to an embodiment of the invention, designed for usein a medical procedure, particularly an arthroscopic surgical procedurefor attaching a suture to a bone, utilizing the two-bore technique ofFIG. 1C for receiving the suture through the two bores B₁, B₂, asbriefly described above, and as to be described more particularly below.

FIG. 2 illustrates the medical implement used for producing bore B₂(FIG. 1C) after bore B₁ has been formed, so that the two bores arelocated to intersect each other at a preselected angle for receiving thesuture. The implement illustrated in FIG. 2 includes a handle 20 havinga proximal end 21 for manual grasping, and a distal end 22 forengagement with the bone to which the suture is to be attached afterbore B₁ has been formed in the bone. As shown in FIG. 2, the distal end22 of the illustrated implement is optionally formed with a ribbed outersurface 23 to enable secure engagement with the bone.

Handle 20 is further preferably formed with a passageway 20 atherethrough extending from the proximal end toward its distal end(FIGS. 2 and 5). As will be described more particularly below, thispassageway is located and configured first to receive a drill for makingbore B₂ (FIG. 1C), and then to receive one end of a suture to beattached to the bone.

The proximal end 21 of the implement illustrated in FIG. 2 is optionallyof an octagonal shape. It is further optionally formed with an elongatedslot 24 longitudinally of its upper face terminating in a transverselyextending slot formed through its two opposed side faces.

The proximal end 21 of handle 20 further carries an optional manuallymanipulatable member 26 optionally including two opposed finger pieces26 a, 26 b connected by a central stem 26 c (FIG. 9) located withinslots 24 and 25 and movable therealong preferably to the ends of the twoslots 24 and 25. The distal end 21 of handle 20 further carries anoptional lock nut 27 having internal threads threadedly received onthreads 27 a formed in the side walls in the proximal end 21 of handle20. As will be described more particularly below, manipulatable member26 is slidable within slot 25, and lock nut 27 is effective to lockmember 26 in its moved position.

The distal end 21 of handle 20 further includes another manipulatablemember 28 having a stem 28 a (FIG. 4) extending through the upper slot24, and an optional knob 28 b engageable by the user for moving member28 to its forward position illustrated in FIG. 2, or to its rearwardposition at the end of slot 24.

The distal end 22 of handle 20 is formed with a slot 29 (FIG. 2) for thereception of a hook, generally designated 30, coupled to manipulatablemember 26 so as to be movable from an extended position, illustrated inFIG. 2, to a retracted position towards the ribbed distal outer surface23 of the handle. Manipulatable member 26 is used for extending hook 30to its illustrated extended position to facilitate reception of the hookinto the first bore B₁ (FIG. 1C) of the bone, and to its retractedposition for clamping the handle to the bone such that the passageway 20a, which is used for making the second bore B₂ (FIG. 1C), is at apredetermined angle (in this case 90°) with respect to, and in alignmentwith, the first bore B₁. Optionally, the angle is 70°. Alternatively,the angle is between 65° and 75° alternatively, the angle is between 30°and 120°. Thus, as shown in FIGS. 2 and 10B, hook 30 includes a firstsection 31 received within slot 29 of the handle, an upwardly-extendingsection 32 joined to a horizontal section 33, and a downwardly-extendingend section 34 to be received within bore B₁, as shown in FIG. 23.

A loop 35 is optionally received within the downwardly-extending endsection 34 of hook 30. It includes a pair of parallel legs 35 a, 35 b(FIGS. 3 and 10D) joined by a bridging section 35 c. As will bedescribed more particularly below, hook 35 is coupled to manipulatablemember 28. Manipulatable member moves the hook to an extended position,as illustrated in FIGS. 2 and 3 or to a retracted position towards thetip of the downwardly-extending section 34 of hook 30. The position ofthe hook in the extended position enables a suture to pass between thetwo legs 35 a, 35 b. Optionally, the hook is then moved to a retractedposition for extraction from bore B₁ (FIG. 1C) of the bone to which thesuture is to be attached.

The manner in which the hook 30 is coupled to manipulatable member 26,in the preferred embodiment, for moving the hook to its illustratedextended position or to its retracted position, is more particularlyseen in FIGS. 8 and 9. As shown particularly in FIG. 8, the central pin26 c of manipulatable member 26 is formed with a bore 26 d into which isthreaded a screw 26 e for securing manipulatable member 26 to anelongated sleeve 40 (FIG. 9) integrally formed with or fixed to the hook30.

As shown in FIG. 5, and more particularly in FIGS. 2, 3 and 10A-10D,loop 35 is slidably received within hook 30. The two legs, 35 a, 35 b ofthe loop normally extend outwardly of the distal end of the hook and arejoined at juncture 35 d to a wire 35 e passing through sleeve 40 of thehook. The proximal end of wire 35 e is fixed to a connector 35 freceiving the stem 28 a of manipulatable member 28 (FIGS. 6A and 6B).

In an exemplary embodiment of the invention, the arrangement is suchthat hook 30 and loop 35 are normally in their extended positions asillustrated in FIG. 2, wherein the leg 34 of loop 30 is spaced away fromthe distal end 22 of handle 20, and loop 35 is extended outwardly of thehook leg 34. In this condition, in accordance with this embodiment, thehook 30 is inserted within bore B₁ (FIG. 1C) of the bone to which thesuture is to be attached, with the loop 35 straddling bore B₁ and spacedaway from the distal tip of leg 34 of the hook in order to receive oneend of the suture to be attached to the bone. This arrangement enablesthe loop to be positioned for receiving the suture from bore B2 and notto collide with residues from drilling bore B2. In this embodiment, boreB2 is narrower than bore B1 thereby enabling the drill forming bore B2to pass through the loop which is inserted through bore B1.

In another embodiment of the invention, hook 30 and loop 35 are in theirretracted position, as shown in FIG. 5, when inserted into bore B1. Theretracted position of hook 30 and loop 35 easies the insertion of thehook into the bore since the end of the hook is more rigid in itsretracted position. Optionally, loop 35 is moved to its retractedposition before forming bore B2 such that the drill forming bore B2 willpass through loop 35.

After the hook has thus been inserted into bore B₁ of the bone, inaccordance with the above described embodiments, manipulatable member 26is moved rearwardly and is locked in position for example by optionallocking nut 27 to firmly clamp the hook to the bone, with the passageway20 a within handle 20 in alignment with bore B₁ and at a predeterminedangle therewith (in this case 90°). A drill is then passed throughpassageway 20 a of handle 20 to drill bore B₂ in the bone intersectingbore B₁ and extending slightly past that bore. After the drill isremoved, the loop is moved to its extracted position if necessary. Oneend of the suture to be attached to the bone is then passed throughpassageway 20 a, and between legs 35 a and 35 b of loop 35 to the end ofbore B₂.

Knob 28 is then moved rearwardly to move loop 35 to its retractedposition, i.e, towards the end hook leg 34, to firmly grasp the suture.The arrangement is such that the two bores B₁, B₂ are located forattaching the suture to the bone, one end of the suture may be extractedvia bore B₁, and the other end of the suture may be extracted via boreB₂.

The Medical Kit of FIG. 11

FIG. 11 illustrates the contents of a medical kit which may be suppliedfor use in performing the arthroscopic surgical procedure describedabove, and to include the medical implement as described above withrespect to FIGS. 2-10D.

Such a kit would include one or more of the following additional tools:a drill guide 51, an obturator 52, and a drill bit 53, for use informing bore B₁ (FIG. 1C) through the bone to which the suture is to beattached; a drill 54 for forming bore B₂ via passageway 20 a ofimplement 50; and a suture loader 55 for forcing the suture, viapassageway 20 a, into bore B₂.

As shown particularly in FIG. 11, drill 54 used for forming bore B₂includes a stop 54 a at its proximal end to define the depth of bore B₂to be produced thereby. The depth of bore B2 should be coordinated withthe length of bore B1 and with the distance between distal end 22 ofimplement 50 and hook 30 after the implement is extended and clamped tothe bone. This distance is varies for different bodies depending on thebone structure of the treated body. Optionally, stop 54 a is not fixedand can be moved to vary the depth of bore B2 for different bones. Insome embodiments, markings are provided on the extended portion ofimplement 50 to indicate the distance of extension. Drill 54 alsoincludes markings which coordinate with the markings on implement 50 andallows positioning of stop 54 a according to the distance between distalend 22 and hook 30 of implement 50. Alternatively, stop 54 a is fixedand such that the depth of bore B2 will suit any bone in a body.

In an exemplary embodiment, drill 53 used for forming bore B1 alsoincludes a stop 53 a. In this embodiment, the position of stop 53 a andstop 54 a are coordinated so that the depth of bores B1 and B2 aredefined and the bores intersect in the bone.

In an exemplary embodiment, drill 54 is narrower than drill 53 such thatdrill 54 will pass through a loop inserted in bore B1 which was formedby drill 53. Alternatively, drill 54 is used for forming both bore B1and bore B2.

In an exemplary embodiment, suture loader 55, as more particularlyillustrated in FIGS. 12 and 13A-13B, includes a shank 55 a formed with anotch 55 b at its distal end and handle 55 c at its proximal end, whichshank is formed with a pair of opposed flat surfaces 55 d parallel tonotch 55 b, to facilitate aligning the suture received within notch 55 bto bore B₁ formed in the bone. Other designs of suture manipulators canalso be used.

In an exemplary embodiment, cannulated drill guide 51 is inserted intopassageway 20 a of implement 50 and is adapted to receive both obturator52 and drill 53. The obturator 52 is inserted within drill guide 51 inorder to locate the exact location of bore B₁ and to clear a paththrough the soft tissue surrounding the bone for the drill to drill boreB1 in the bone. The obturator is then removed to enable drill 53 todrill bore B₁ via guide 51. After bore B₁ has been drilled, medicalimplement 50 is then used to drill bore B₂ by inserting hook 30 intobore B₁ to locate passageway 20 a of implement 50 in precise alignmentwith bore B₁ and at a predetermined optimum angle thereto. In somesituations an obturator may not be required.

Drill 54 is then passed through passageway 20 a of implement 50 to drillbore B₂. Drill 54 is then removed and knob 28 is moved to extend loop 35from hook 30, if it was not already extended during the drilling of boreB₂. The suture to be attached to the bone is then fed through passageway20 a by suture loader 55 traversing bore B₁ between the two legs 35 a,35 b of loop 35 to the end of bore B₂. Optionally, drill 54 iscannulated and the suture is threaded through cannulated drill 54. Inthis option, the drill is removed after the thread is already in placeor together with the entire implement. Loop 35 is then retracted withinthe end of hook 30 and to firmly clamp the suture to the end of hook 30.Hook 30 is removed from bore B₁ to expose the clamped end of the suture,and handle 20 of implement 50 is also removed to expose the other end ofthe suture. Accordingly, with the suture passing through the two boresB₁ and B₂, and the two ends of the suture exposed outwardly of thesebores, the sutures may now be used for attaching the bone tendon to thebone, or for any other purpose, instead of the anchor pins as previouslyused.

It will thus be seen that the implement and kit described areparticularly useful for arthroscopic medical procedures to attach atendon to a bone, such as to repair a damaged shoulder joint. However,the invention could also be used in open surgical procedures, or forother procedures requiring the attachment of a suture to a bone insteadof anchor pins heretofore used for such purposes.

Variation in Use of Medical Kit

FIGS. 14 and 15 illustrate a variation wherein one end of the suture isaccessed and extracted via bore B₁, not by the loop 35 as describedabove, but rather by a suture hook, generally designated 56 in FIGS. 14and 15. Such a suture hook includes a shank 56 a formed with a crochetnotch 56 b at its distal end, and an optional handle 56 c at itsproximal end. Such a suture hook enables the end of the suture receivedwithin bore B₂ to be accessed and extracted via bore B₁, therebyobviating the need for the loop 35 in implement 50 as described abovewith respect to FIGS. 2-10D. Suture hook 56 illustrated in FIGS. 14 and15 may thus also be included in the tool kit illustrated in FIG. 11 tobe used instead of the loop 35 of implement 50.

the Medical Implement of FIGS. 16-21

FIGS. 16-21 illustrate another bone-tunneling implement constructed inaccordance with an embodiment of the present invention, generallycorresponding to the implement described above with respect to FIGS.2-10D, but incorporating a number of modifications.

In the bone-tunneling implement illustrated in FIGS. 2-10D, the hook 30is the movable element movable with respect to the distal end of thehandle 20 in order to facilitate the reception of the hook into thefirst bore B₁, and for clamping the handle to the bone at apredetermined angle with respect to the first bore. In the medicalimplement of FIGS. 16-21 this arrangement in reversed; that is, in themedical implement of FIGS. 16-21, the movable member is the distal endof the handle, which is movable towards and away from the hook. Such anarrangement has the advantage of simplifying the mechanism for movingthe movable element.

Another difference in the structure of the medical implement of FIGS.16-21, over that of FIGS. 2-10D, is that the manipulatable member orknob 28 in FIGS. 2-10D is not slidable along an axis parallel to thelongitudinal axis of the handle, but rather is pivotal along a pivotaxis perpendicular to the longitudinal axis of the handle. In addition,the lock nut 27 used in the medical implement of FIGS. 2-10D to lock themanually-manipulatable member 26, is omitted. Such features not onlysimplify the structure, but also facilitate its use by the surgeon.

The medical implement illustrated in FIGS. 16-21 is generally designated100. It includes a handle 120 having a proximal end 121 for manualgrasping, and a distal end 122 for engagement with a bone in which asuture is to be attached. As in the previously-described embodiment, thebone would be pre-formed with a first bore B₁ (FIG. 1C). The medicalimplement of FIGS. 16-21 also includes a hook 130 at the distal end ofthe handle, and a loop 135 movable to an extended position with respectto the hook for facilitating entry of one end of the suture through theloop, and to a retracted position for clamping the respective end of thesuture, as described above with respect to FIGS. 2-10D.

In the implement of FIGS. 2-10D, the hook (30) is the movable elementwith respect to the distal end (22) of the handle; the construction ofFIGS. 16-21 reverses these parts. That is, in the construction of FIGS.16-21, the hook 130 is fixed, and the distal end 122 of the handle ismovable towards and away from the hook in order to facilitate the entryand removal of the hook into the first bore B₁.

This feature can be best seen in FIG. 19, wherein it will be seen thatthe handle 120 is hollow, and slidably receives a core 123 having adistal end 122 movable towards and away from the hook 130.

As clearly seen in FIG. 19, core 123 is urged by a spring 124 in thedirection of bringing the distal end 122 into engagement with the hook130, but may be manually moved rearwardly by means of manipulatablemember 126 having a stem passing through longitudinal slots 127 (FIG.18) in handle 120 so as to permit the distal end 122 to be retractedrearwardly of hook 130 against the bias of spring 124. As further seenparticularly in FIG. 19, the core 123 is formed with passageway 120 a(corresponding to passageway 20 a in FIGS. 2-10D) used for making asecond bore B₂ shown in FIG. 1C. At the distal end 122, passageway 120 ais a slot in core 123.

Loop 135 received within hook 130 is basically of the same constructionas described above with respect to loop 35 in FIGS. 2-10D, in that it iscoupled to knob 128 to move the hook to its extended and retractedpositions in order to grasp a suture passed between the two legs of thehook for extraction from bore B₁, as described above with respect toFIGS. 2-10D. The coupling of the loop 135 to knob 128 is also effectedby means a wire 135 e passing through the distal end of handle 120.

In the implement of FIGS. 16-21, however, manipulatable knob 128 forloop 135 is pivotal about an axis 128 a extending perpendicularly to thelongitudinal axis of the handle 120 and located slightly above thatlongitudinal axis, as can be seen particularly in FIG. 19. Thus, asshown in FIG. 19, loop 135 would normally be urged, by spring 124 to itsretracted position within hook 130 (FIG. 19), but is convenientlymovable to its extended position, shown in FIG. 18, by merely pivotingknob 128 forwardly, whenever it is desired to extend the loop forreceiving the end of the suture. Releasing the knob will then effect theretraction of the loop to firmly grasp the suture, as described abovewith respect to the implement of FIGS. 2-10D.

In addition, whereas hook 30 shown in FIG. 2 formed an angle of about90° between horizontal section 33 and end section 34, in the embodimentshown in FIGS. 16-21, hook 130 forms a larger angle of about 110°-115°between horizontal section 33 and end section 34. Accordingly, with thisembodiment, the angle between bores B1 and B2 formed using implement 100is about 65°-70°.

In substantially all other respects, the bone-tunneling implementillustrated in FIGS. 16-21 is constructed, and operates, in the samemanner as described above.

It is to be understood that, where applicable, implements according tovarious embodiments of the invention can include features taken fromboth described embodiments of the bone-tunneling implements.Furthermore, it should be clear that other methodologies to provide thefunctions performed by the two above embodiments can also be used.

Method of Attaching a Suture to a Bone (FIGS. 22 and 23A-G)

FIG. 22 is a block diagram of a method 220 of attaching a suture to abone in accordance with an exemplary embodiment of the invention. FIGS.23A-G are illustrations of stages of method 220. the illustrations anddescription below refers to implement 100 shown in FIGS. 16-21. It isnoted that method 220 with appropriate changes may be applied withimplement 50 shown in FIG. 2-10D or other variations of the implement.

A first bore B1 is formed in the humerus bone at 222. Preferably, boreB1 is formed near the greater tubercle 6 shown in FIG. 23A and FIGS.1A-1C and is not long enough to exit the bone. Optionally, as shown inFIG. 23A, bore B1 is drilled with a drill bit 53 inserted through drillguide 51. Optionally, an obturator is first inserted through drill guide51 in order to clear a path through the soft tissue surrounding thebone. Alternatively, bore B1 is formed by any other method known in theart.

Hook 130 is then inserted into bore B1 at 224. Optionally, the hook isinserted through drill guide 51, as indicated in FIG. 23B, in order toease locating bore B1 and the drill guide is removed after insertion.

Optionally, the insertion of the hook into bore B1 is used as areference point for forming bore B2, such that bores B1 and B2 intersectat a predetermined angle. Alternatively or additionally, hook 130 isused as an arm clamping implement 100 to the bone. Before inserting hook130 to bore B1, manipulatable member 126 is moved rearwardly so aspermit distal end 122 of the core to be retracted rearwardly of hook130. After insertion of hook 130 in bore B1, manipulatable member 126 isreleased and distal end 122 is clamped to the bone by bias of spring 124as shown in FIG. 19, or otherwise.

FIG. 23C depicts the hook inserted into the first hole and distal end122 clamped to the bone. As further shown in FIG. 23C, manipulatableknob 128 is moved to shift loop 135 to its extended position.

At 226 a second bore B2 is formed through the bone (FIG. 23D) at apredetermined angle from bore B1. Bore B2 is drilled to a depth suchthat bore B2 meets bore B1 in the humerus bone thereby enabling a sutureto be threaded through the two bores. Preferably, bores B1 and B2 extendpast the intersection of the bores in the bone such that drill 54 passesthrough loop 135 in bore B1. Preferably, bore B2 is not long enough toexit the bone. Optionally, bores B1 and B2 define a 70° angle in thebone. Preferably, bores B1 and B2 define an angle of between 65° and 75°in the bone.

Optionally, before drilling bore B2, an obturator, such as the obturator52 shown in FIG. 11, is used to clear the path and locate the exactlocation of bore B2. Bore B2 is then drilled at the location indicatedby the obturator, using a drill such as drill 54 shown in FIG. 11.

After forming bore B2 a first end of a suture 57 is threaded throughbore B2 at 228. As shown in FIG. 23E, a suture loader such as sutureloader 55 depicted in FIG. 12 is optionally used for threading suture 57through bore B2 and through loop 135 extending from hook 130. Sutureloader 55 is then removed, leaving suture 57 in the bore.

At 230 the first end of the suture is caught at the intersection ofbores B2 and B1 by loop 135. Manipulatable knob 128 is moved to shiftloop 135 to its retracted position inside hook 130. Suture 57 which wasthreaded through loop 135 is now caught inside hook 130.

At 232 manipulatable member 126 is moved to release distal end 122 frombeing clamped to the bone. Hook 130 is removed from bore B1 and suture57 which is clamped in hook 130 is thereby threaded through bore B1. Theend of the suture is then extracted from the bone by threading throughbore B1 at 232. As shown in the magnified section of FIG. 23G, suture 57is now threaded through a channel in the bone consisting of bores B1 andB2.

In an alternative embodiment, the suture is first threaded into bore B1and caught through bore B2.

At 233 the suture is threaded through the tendon according to anyprocedure known in the art. The tendon is then pulled into place bymeans known in the art. At 234 the two ends of the suture, the first endextending from bore B1 and the second end extending from bore B2 andtendon 10 may be knotted together thereby attaching the tendon to thehumerus bone. FIG. 23H is a coronal section view of a humerus boneillustrating a suture knotted through the bone and tendon. The suture,threaded through a into bore B1 is exited bore B2 at b, retrievedthrough tendon 10 at c and is knotted at d. FIG. 23I is a lateral viewof a row of sutures tied over tendon 10 in accordance with an exemplaryembodiment of the invention. A first suture is passed through the boneat a1 to b1 and retrieved through the tendon at c1 and then knotted atd1. A second suture is passed through a channel in the bone from a2 tob2 and passed through the tendon at c2 to be knotted at d2 etc.

FIG. 23J illustrates a lateral view of another embodiment of theinvention where two sutures are passed through a single bone channel andare tied over different locations through the tendon. For example, afirst and a second suture are threaded through a bone channel from a1 tob1. The first suture is retrieved through the tendon at c11 and knottedat d11. The second suture is retrieved through the tendon at c12 andknotted at d12.

It is noted that a plurality of ways of tying the sutures are known inthe art. FIGS. 23I-J are provided an example and other methods such asfor example crossing the sutures over the tissue, to increase the areaof the tendon held against the bone, are also covered by the presentinvention.

the Medical Implement of FIG. 24

In another embodiment of the invention, bores B1 and B2 are formed witha same implement 240 as shown in FIG. 24.

Implement 240 includes two channels 242 and 244 for receiving tools suchas drills, holders, etc. Instrument 240 is brought close to the bone atthe greater tubercle 6. A drill, such as drill 53 shown in FIG. 11, isinserted into channel 242 for forming a first bore B1. Optionally, anobturator, such as obturator 52 shown in FIG. 11, is first inserted intochannel 242 for clearing the path through the soft tissue and indicatingthe location of bore B1.

A pin or hook is then inserted into channel 242 and bore B1 forpositioning implement 240 to the bone in order to stabilize theimplement when forming a second bore B2. Optionally, the drill used forforming bore B1 is kept in the bore for stabilization of implement 240and a second drill is used for forming bore B2.

A drill is then inserted through channel 244 and second bore B2 isformed. Channels 242 and 244 are located in implement 240 such thatbores B1 and B2 formed with drills inserted through the channels,intersect in the bone. Preferably, bores B1 and B2 are not long enoughto exit the bone. Optionally, a stop on the drill forming bores B1 andB2 causes the bores to be formed to a certain depth such that the boreswill intersect in the bone and will not cross the bone.

In the embodiment shown in FIG. 24, the angles formed between the boresis preferable less than 90° so as to allow the two bores to be formedfrom the same side of the bone. Optionally, the bores define an angle ofless than 45° in the bone. Optionally, the bores define an angle of lessthan 30° in the bone.

Implement 240 further comprises two channels 246 and 248 for receiving asuture. Channels 246 and 248 join with channels 242 and 248 atintersection points 250 and 252 respectively. After bores B1 and B2 areformed, a suture is inserted through channel 246 and bore B1 and isretrieved through bore B2 and channel 248 in a manner similar to thatdescribed with respect to the embodiments shown in FIGS. 2 and 16 above.

It will be appreciated that other variations, modifications andapplications of the invention may be made. For example, other means maybe used for extracting the end of the suture via bore B₁ than thosedescribed above. In addition, other constructions of the slidablemanipulatable members 26 and 28 may be used for removing the hook and/orthe loop. The couplings of manual manipulatable member 26 may include aslip or yielding coupling in order to prevent excessive force from beingapplied by hook 30 to the bone, and thereby reduce the possibility ofbreakage of the bone.

Many other variations, modifications and applications of the inventionwill be apparent.

What is claimed is:
 1. A medical implement, comprising: a hook forinserting in a first bore in a bone; and a passageway for placement atan entrance to a second bore in the bone, wherein said hook comprises agrasper extending therefrom, said grasper being adapted to grasp an endof a suture inserted through the passageway and through the second bore.2. The implement according to claim 1 wherein said hook is furtheradapted to extract the suture through the first bore.
 3. The implementaccording to claim 1 further comprising a movable member for clampingwalls of the passageway against the bone when the hook is inserted intothe first hole.
 4. A method of forming a bore in a bone, the methodcomprising: providing an implement comprising a hook having an endportion for insertion in a first bore in a bone and a passageway forreceiving tools, the passageway being at a non-zero angle to the endportion; retracting the passageway with respect to the hook; insertingthe hook in the first bore; clamping the passageway to the bone; andforming a second bore in the bone using a drill inserted through thepassageway.
 5. A method according to claim 4, wherein forming a secondbore comprises forming a second bore which intersects with the firstbore.
 6. A method according to claim 4, wherein forming a second borecomprises forming a second bore which intersects with the first bore inthe bone.
 7. A method according to claim 6, wherein forming a secondbore comprises forming a second bore extending past the intersection ofthe first and second bore in the bone.
 8. A method according to claim 6,wherein the first bore extends past the intersection of the first andsecond bore in the bone.
 9. A method according to claim 4, whereinretracting the passageway comprises retracting against the biasing of aresilient member.
 10. A method according to claim 9, wherein clampingthe passageway comprises pushing the passageway against the bone by saidresilient member.
 11. A method according to claim 4, wherein thepassageway has a longitudinal axis and is comprised in an elongateelement and wherein the hook is formed at the end of the elongateelement and the end portion of the hook is at an angle to thelongitudinal axis.
 12. A method according to claim 4, wherein thepassageway has a longitudinal axis and is comprised in an elongateelement and wherein the hook comprises an upwardly-extending sectionwith respect to the longitudinal axis joined to a horizontal sectionwith respect to the longitudinal axis, and a downwardly-extending endsection with respect to the longitudinal axis and wherein inserting thehook through the first bore comprises inserting the downwardly-extendingend section in the first bore.
 13. A method according to claim 5,further comprising: threading a first end of a suture through the secondbore, while leaving a second end outside the bone; capturing the firstend of the suture from the first bore at the intersection of the bores;and threading the first end of the suture through the first bore.
 14. Amethod according to claim 4, further comprising inserting a grasperthrough the first bore.
 15. A method according to claim 14, wherein thedrill passes through the grasper when forming the second bore in thebone.
 16. A method according to claim 14, further comprising threading afirst end of a suture through the second bore and through the grasper.17. A method according to claim 16, further comprises threading thefirst end of the suture through the first bore using the grasper.
 18. Amethod of threading a suture through a first and second bore in a bone,the method comprising: providing an implement comprising a hook havingan end portion for insertion in the first bore and a passageway forreceiving tools, the passageway being at a non-zero angle to the endportion; inserting the hook and a grasper through the first bore in thebone; clamping the passageway to the bone; forming the second bore inbone using a drill inserted through the passageway; threading a firstend of a suture through the second bore and through the grasper; andthreading the first end of the suture through the first bore.
 19. Amethod according to claim 18, wherein threading the first end of thesuture through the first bore comprises threading by retracting thegrasper from the first bore.
 20. A method according to claim 18, whereinthe drill passes through the grasper when forming the second bore in thebone.
 21. A method according to claim 18, wherein the grasper comprisesa loop.
 22. A method according to claim 18, wherein the passageway has alongitudinal axis and is comprised in an elongate element and whereinthe hook is formed at the end of the elongate element and the endportion of the hook is at an angle to the longitudinal axis.
 23. Amethod according to claim 18, wherein the passageway has a longitudinalaxis and is comprised in an elongate element and wherein the hookcomprises an upwardly-extending section with respect to the longitudinalaxis joined to a horizontal section with respect to the longitudinalaxis, and a downwardly-extending end section with respect to thelongitudinal axis and wherein inserting the hook through the first borecomprises inserting the downwardly-extending end section in the firstbore.